What's Up Doc? Don't ignore groin pain

Dr. Jeff Hersh

Monday

Aug 27, 2007 at 12:01 AMAug 27, 2007 at 8:51 PM

Fournier's Gangrene, also called Fournier's disease, is an uncommon but serious infection of the skin and deep tissues (the fascia, which is fibrous connective tissue) around the groin area. Dr. Jeff Hersh gives you the lowdown.

Q: My uncle went to the emergency room because he had severe pain in his groin. It turns out he was lucky he went, because they had to rush him to surgery to treat an infection in his scrotum. Can you tell me about this condition?

A: Although Fournier's Gangrene, also called Fournier's disease, is a pretty uncommon disease, it sounds like that is what your uncle had, so that is what I will discuss in today's column.

In 1764 a French physician, H. Baurienne, was the first to describe a patient who had necrotizing gangrene of the male genitalia. However, in 1883 another French physician, Jean-Alfred Fournier, gave a series of lectures on patients who presented with this condition, and Fournier's Gangrene (FG) is named after him.

FG is a serious infection of the skin and deep tissues (the fascia, which is fibrous connective tissue) around the groin area. Most cases of FG are actually due to several different types of bacteria at the same time (in some cases other infectious organisms, such as fungi, can be involved) and, in fact, studies have shown that on average four kinds of bacteria are found in the skin and deep tissues of people suffering with this disease.

In many cases, a suspected source of the bacteria, which "seeds" the tissues, is identified. Common culprits include abscesses (pus pockets under the skin) from the rectal or scrotal areas, other skin infections, bacteria from the colon (due to a colon perforation, a fistula or other conditions), infections of the genital organs (such as the testes or epididymis) or complications from surgery or from some other trauma.

Men are affected 10 times more often than women, but the disease itself is very uncommon in either sex, and only about 600 cases have been reported in literature in the past 10 years. Risk factors for getting FG are diabetes, obesity, any condition that compromises the immune system (including HIV), alcoholism (or cirrhosis) and advanced age (especially age over 60).

Patients who develop FG usually have symptoms that start in a subtle way. There may be a discomfort in the groin area that progresses to pain and worsens over a couple of days. In fact, most people diagnosed with FG have had symptoms for an average of five days or so before seeking medical care.

Early in the course of the disease, the skin over the affected area may have less worrisome changes including redness, warmth and swelling. As the infection worsens the skin can develop bullae (like a large blister), and then becomes necrotic (where the tissue dies, usually appearing as a black-gray area). Some of the bacteria that can be involved in FG can excrete gases, so crepitus (where the tissue can "crackle" when being pushed on, feeling like cellophane being rolled up) can develop, and for those patients with this kind of bacteria this physical finding can aid in making the diagnosis.

As FG progresses, patients with it can become systemically ill, developing fever and fatigue. Since patients wait five days, on the average, before seeking medical care, it is actually common that FG patients are systemically ill at the time of diagnosis.

FG is usually suspected based on the history and physical exam. For example, a 60-year-old morbidly obese man with diabetes who presents with worsening pain in his scrotum and who has fever and a necrotic area of skin will most likely be diagnosed with FG. Although a CT scan (or in some cases a plain X-ray, an ultrasound or even an MRI) can help in making the diagnosis (often by identifying gas trapped in the underlying tissues), the definitive diagnosis can only be made by directly visualizing the area in the operating room during surgery, and by analysis of surgical specimens and cultures from these specimens.

FG is a very severe condition. Reports of mortality from this condition vary widely in literature, from 4 percent to 75 percent, but most authors quote 20 percent to 30 percent death rates in patients with this disease. Since there is no reliable test to diagnose FG, it is important for health care providers to maintain a high index of suspicion for this condition.

Treatment of FG is broad-spectrum antibiotics and, most importantly, emergency surgery to debride (cut out) the necrotic tissue and to stop the infection from spreading.

Anyone who develops severe unexplained pain anywhere in the body should be evaluated by a health care provider. FG is a necrotizing infection of the perineal area (the part of the body in the pelvic area with the urogenital and rectal organs, located between the hip bones and coccyx and wrapping around to the genitals), but necrotizing skin infections can occur in essentially any part of the body. A high index of suspicion is needed to make the correct diagnosis, and treatment with broad-spectrum antibiotics and emergency surgery can help minimize the adverse outcomes of these severe and potentially life-threatening infections.